Category Archives: Erectile Dysfunction

“An infection after placement of a penile implant is a potentially dangerous problem. The article below published on ABC news highlights the issues surrounding the controversial case of a Miami urologist who placed a penile prosthesis in a diabetic patient which resulted in a severe infection necessitating penile amputation. Fortunately, infections after placement of penile implants are rare complications. The penile implants that I place manufactured by AMS are antibiotic coated and have an infection rate of less than 1%. Although having diabetes is certainly not a contraindication to placement of a penile implant, certainly having poorly controlled diabetes increases a patient’s risk for developing an infection. For this reason, it is important for urologists to pay attention to a patients diabetes control and evaluate the hemoglobin A1c which is an indicator of the patients diabetes control over the past several months. In my practice, if a patient has refractory erectile dysfunction and is interested in a penile implant, but his hemoglobin A1c is elevated, I defer placement of the penile prosthesis until the patient in combination with his primary care physician or endocrinologist is able to improve his patients diabetes control and bring the hemoglobin A1c back down to normal levels. Unfortunately, even under optimal conditions, an infection can occur. The most important factor in the context of an infection of a penile prosthesis is early recognition and intervention to prevent severe complications such as a penile amputation as highlighted in the article below. “

Diabetic Sues Doctor After His Infected Penis Is Amputated

A man who elected to have a penile implant in a Florida hospital is now suing his doctor after a post-surgical infection resulted in the amputation of his organ.

Enrique Milla, 65, who was reportedly deported from the United States last year back to his native Peru, has been testifying in court via Skype that the medical procedure robbed him of his dignity and manhood.

In a medical malpractice trial that began this week, Milla claims that his doctors should have known that he was not a good candidate for the procedure because of his diabetes and high blood pressure.

“This has been devastating, painful and embarrassing,” said Milla’s attorney, Spencer Aronfeld of Coral Gables, according to ABC’s affiliate WPLG.

Milla alleges that his anesthesiologist Dr. Laurentiu Boeru “failed to evaluate properly the risks of this procedure.” He first filed the lawsuit in 2009, naming Boeru and Dr. Paul Perito, the urologist who performed the surgery.

According to the Miami Herald, which obtained records that are not publicly available, Perito settled the case out of court.

“At the end of the day, he has to sit down to pee through a tube,” Aronfeld told the Herald.

Penile implant surgery is most commonly performed after all other treatments for erectile dysfunction have failed. It is also used to treat some cases of Peyronie’s disease, a condition that causes scarring inside the penis, leading to bent, painful erections.

Implant surgery comes with a risk of infection, which can occur at any time after surgery — in rare cases, even years later, according to the Mayo Clinic.

Milla suffered from a number of medical conditions, including erectile dysfunction, according to court records. Milla, who had lived in Miami for 40 years working in a medical supply business, received the surgery in 2007 at Coral Gables Hospital.

“He didn’t do this to have a bigger penis,” said Aronfeld. “This was because of medical reasons: He just wanted to have relations with his wife.”

But two weeks after the operation, Milla developed an infection that eventually turned to gangrene. Amputation of his penis was necessary to save his life, according to his lawyer, who alleges Boeru didn’t exercise proper care after the surgery.

“Post-operative period is about anywhere between six to 24 hours after surgery. It does not include either days or months,” testified Boeru.

“This is an infection that occurred in this gentleman because he didn’t do what he was supposed to do post-operatively nine days after the surgery,” Boeru’s lawyer Jay Chimpoulis, told WPLG.

He suggested that Milla ignored medical instructions to avoid sex and developed a fecal infection.

“There are any number of ways he could’ve gotten that. None of them had anything to do with [Boeru],” Chimpoulis said.

Dr. Pravin Rao, director of reproductive medicine and surgery at the Johns Hopkins Brady Urological Institute, said penile implants, called prostheses, are safe for patients who are in good health — even those with diabetes, as long as the disease is “controlled.”

The risk rate is lower than 3 percent, according to Rao, who did not treat Milla.

“Usually, it’s the last report option for men who just don’t want to use other treatments as options,” he said. “Sometimes, the individual wants a permanent solution and wants the spontaneity.”

Penile implants are among a “long algorithm of options” for those with erectile dysfunction, according to Rao. Urologists start with pills like Viagra — the least invasive approach –– to vacuum erection devices and injection therapy.

But sometimes those treatments fail because of the quality of the tissue in the penis or poor blood flow.

The most common reason for ED is chronic disease that affects the vessels in the penis — most often diabetes, hypertension, smoking or high cholesterol. Nerve damage, caused by spinal cord injuries, diabetes or radical prostate cancer surgery, can also trigger ED.

A poor candidate for a prosthesis is someone who is not in overall good health and may be at risk under anesthesia or not be able to withstand the blood loss of surgery.

“The number one concern is infection, and that’s why we make sure their overall health and immune status are good and their diabetes is under control,” said Rao.

When infection does occur, the prosthesis must be immediately removed to clear the infection.

“Personally, I have heard of amputation, but not seen one,” said Rao. “We have definitely seen prostheses taken out due to erosion. The wrong size is chosen or there is poor wound healing.”

The prosthesis is an inflatable device that is inserted in the two tubes of the penis. The balloons can be filled up with fluid, creating an erection. A small pump is placed in the scrotum with a reservoir of fluid that connects to the tubing.

“When we first place it, we don’t have it activated to create a full erection,” said Rao. “Then after letting it heal for six weeks, [the patient] comes in and we teach them how to use the pump by squeezing it.”

Patients are told not to have sex during that recuperative period.

Rao said that penile implants are “very successful and infection is not the norm.”

Some studies of patients with diabetes and those without the disease had the same rate of infection. “But,” he said. “We have to be prudent about picking the patient.”

Penile prosthesis surgery (penis implant/penile pump) is an excellent option to regain erectile function in cases of erectile dysfunction refractory to traditional medical treatments such as with oral medications, intraurethral suppositories or injection therapy. A 3 piece penile prosthesis consists of a pump in the scrotum that allows the user to self inflate and deflate at will with ease, two erectile cylinders placed into the corpora cavernosum (erectile bodies) and a reservoir of fluid located below the abdominal fascia placed through the same single incision. When an erection is desired, the pump is activated thereby permitting fluid to flow into the cylinders. The entire device is implanted in the patients body without alteration of the natural body contour. It would not even be noticable in a locker room.

The 3 piece penile prosthesis (penis implant/penile pump) provides for a natural appearing erection with greater flaccidity when the prosthesis is in the deactivated position as compared to the two piece penile prosthesis or malleable penile implant. Each prosthesis is custom made to fit the natural size of each individual patient. The most advanced and up to date AMS penile prosthesis typically placed by Dr. Wirtshafter and Dr. Robbins provides both girth and length expansion.

A three piece penile prosthesis (penis implant/penile pump) is ideal for a patient with refractory erectile dysfunction with adequate manual dexterity and good mental capacity desiring a natural appearing erection with more natural flaccidity than a malleable penile implant or a two piece penile prosthesis .

Penile implant surgery (penis implant/penile pump) is an excellent option for patients with erectile dysfunction and Peyronie’s disease (penile curvature). In this circumstance, a penile implant can be used to simultaneously correct the curvature and provide excellent erectile function.

Considerations for choosing the appropriate implant include lifestyle, medical conditions, personal preference and cost. As with all surgeries, there are associated risks that include infection, pain and other complications.

Miami urologists Dr. David Robbins and Dr. Amery Wirtshafter have significant experience with penile prosthesis surgery even in complex cases and have helped countless patients to regain their sexual function and confidence.

By Elizabeth Cohen, CNN Senior Medical Correspondent August 25, 2011 7:24 a.m. EDT The penis is a highly vascularized organ, which means there’s a lot of blood running through it, so cutting into it can be risky.STORY HIGHLIGHTS Doctors urge men with erectile dysfunction to try other, less risky, treatments first For implants, also try to find a doctor who does at least two or three a month Cutting into the penis leaves you vulnerable to infection RELATED TOPICS Male Sexual Dysfunction Men’s Health Sexual and Reproductive Health Surgery (CNN) — If you’re a woman contemplating surgery on your female parts, you’ll find plenty of ladies chatting and blogging away about their experiences, often on websites adorned with pink ribbons. But if you’re a man considering male surgery there’s not so much out there. There’s no ribbon for, say, penis surgery, and comparatively few men trading stories and sharing advice. “Women are much more engaged with their health,” says Dr. Dennis Pessis, president-elect of the American Urological Association. “It’s gotten better in the past 15 years, but still, men don’t always seek out the best treatments for themselves.” Penis surgery has been in the spotlight this week as a civil trial in Kentucky made national headlines. Phillip Seaton, a Kentucky truck driver, sued his urologist, Dr. John Patterson, saying he went in for a circumcision but left the surgery with part of his penis amputated. Patterson says Seaton had cancer and needed the amputation or he would have died. The doctor won the case on Wednesday, according to CNN affiliate WDRB. Seaton’s experience is certainly rare, surgery on the penis isn’t. While good statistics are hard to find, tens of thousands of men in the United States get circumcised as adults. Other common surgeries include implants for men suffering erectile dysfunction and removal of genital warts. Here’s the Empowered Patient list of questions every man should ask before having these procedures on this most valued and delicate of organs. 1. Do I really need this procedure? Think twice (or more) before having the surgery. It’s a highly vascularized organ, which is a fancy way of saying there is a lot of blood running in and out of it, so cutting into it can be risky. Men getting circumcised as adults should consider the risk of bleeding, especially if they’re on a blood thinner, including aspirin. Getting implants requires cutting, too, and doctors urge men with erectile dysfunction to try other, less risky, treatments first, such as drugs like Viagra, penile injections, or a penis pump, an external device that fits over the organ. You’ll also need to choose what kind of anesthesia you’ll want for your circumcision. You can opt for a local anesthetic and a sedative — you’ll be (or should be) relaxed but awake. Men who are especially anxious about the surgery often opt for general anesthesia, which is slightly more risky but ensures they’ll be totally out for the procedure. As for genital warts, if a man is not experiencing problems such as itching, burning or pain, he may not need treatment, according to the Mayo Clinic. 2. What are my treatment options? There is more than one type of penile implant and there is more than one way to remove genital warts. Doctors tend to specialize in one method over the other, so make sure your doctor lays out all the options and refers you to another doctor who can perform the procedure the way you prefer. There are two types of implants. With inflatable implants, doctors put cylinders inside the penis, a pump in the scrotum, and a fluid reserve inside either the scrotum or the abdominal wall. Before sex, you pump the fluid into the cylinders to create an erection. After sex, you activate a release valve in the scrotum to let the fluid out. The second type of implant involves putting semi-rigid rods into the penis, and it is bent away from the body to have sex (think of it as a goose-necked desk lamp that can be pointed in various directions). For more on various types of penile implants, see information from the Mayo Clinic and the American Urological Association. For warts, you can treat them yourself or your doctor can treat them. If you choose the DIY approach, your doctor prescribes a medicine for you to apply at home. If you prefer to have your doctor treat the warts, there are several options: Your doctor can apply a medicine, which is sometimes a stronger version of what you can apply at home. There is also an option to cauterize or laser the warts, or to freeze them off with liquid nitrogen. “You should give yourself some time to make the right decision,” says Dr. Gopal Badlani, a urologist at Wake Forest Baptist Medical Center. “You don’t want to decide at the first appointment.” For more information on the various options for removing genital warts, see information from the Centers for Disease Control and Prevention. 3. Doctor, how many of these procedures have you done? Look for a urologist who regularly performs the procedure you need. “Some urologists do nothing but treat kidney stones or urinary incontinence, and you don’t want that urologist doing your circumcision,” says Dr. Irwin Goldstein, director of San Diego Sexual Medicine. “They need to know what they’re doing so they don’t remove too much or too little skin, or create a new problem like an angled penis.” While there’s no magic number, Goldstein says if you’re having a circumcision, find someone who does at least two or three a month. Plus, you should ask the doctor for names of his or her previous circumcision patients. “It’s sort of like fixing your roof — you want to talk to a client who’s used that roofer,” he advises. “Ask about the doctor’s follow-up: Was he available, or did he just do the surgery and you didn’t hear from him again?” For implants, also try to find a doctor who does at least two or three a month, Goldstein advises, not someone who just dabbles in the procedure. “We did three implants Monday, just to give you a sense of how often some doctors do these,” Goldstein adds. The removal of genital warts isn’t as complicated as circumcision or implant surgery, but still make sure it’s something your doctor does regularly. 4. Will the treatment really cure my problem? Badlani says no matter how much he counsels his patients before implant surgery, most are disappointed the implants didn’t give them as large an erection as they had when they were 18. “Ninety-five percent of the time, after the surgery the patient feels shortchanged. They say, ‘Doc, I expected it to be much longer,’ ” Badlani says. “Men need to have more realistic expectations.” Men are also sometimes surprised that their genital warts come back after treatment. But the Mayo Clinic says genital warts “are likely to recur” because even after you remove them, you still carry the virus that causes warts, called the human papillomavirus (HPV). 5. Should I clean up before the surgery? Cutting into the penis leaves you vulnerable to infection, so ask your doctor if you should be scrubbing at home before surgery day. Goldstein tells his circumcision patients to clean with a special antiseptic once a day for three days before the surgery. He has his implant patients wash up morning and night for seven days before surgery, and take antibiotics for three days before. “We’re inserting a foreign body into the penis. The chances for things to go wrong are magnified, so we want to take all precautions,” he says. CNN’s Sabriya Rice contributed to this report.

The British Journal of Urology reports Tuesday that men who take multiple medications may be increasing their risk for erectile dysfunction. Although some of the conditions they’re being treated for might carry an ED risk, the medication on its own may also increase the danger of erectile problems.

Researchers from Kaiser Permanente surveyed 37,712 men who were part of the California Men’s Health Study about their health and current medications. More than half the men — 57% — were taking more than three medications, and higher drug use was found among older study participants and those who were African American. Taking more medications was also linked with a higher body mass index.

Overall, 29% of men surveyed said they had experienced moderate to severe erectile dysfunction. Frequency of ED was associated with taking a larger number of medications. Among men taking up to two medications, ED prevalence was 15.9%; among men taking three to five medications it was 19.7%, among men taking six to nine medications it was 25.5% and among men taking 10 or more medications it was 30.9%.

When researchers controlled for factors that could also affect ED, such as age, diabetes, high blood pressure and smoking, taking more medications was still associated with a greater risk of ED.

“Clinically, the findings from this study suggest that a crucial step in the evaluation of ED would be to review the current medications the patient is taking and their potential side effects,” said lead author and urologist Dr. Diana Londono in a news release. “When appropriate, decreases or changes in the amount or type of medication should be considered.”